Simple contact form webpage

Hi, I need someone to build a very simple webpage that will allow users to enter their comments and contact details and then upon the form being submitted, I will need it have info to be forwarded to my email address.

This is quite a simple job for the right person and I have the graphics and text ready for you to use as attached, the form will need to appear in the middle of the graphic.

I will require the winning applicant to also upload the page. Applicant must have previous experience and feedback on freelancer.